“This problem is not unique to our Trust,” states Jonathon Artingstall, Associate Director Information & Performance at Cambridgeshire and Peterborough NHS Foundation Trust. “We’ve taken lots of data in all shapes and formats from different systems and put it into a cloud storage solution so it can be used today. Who knows what lies in those 23 years of data? Now we have the capability to explore that.”
A shift to the cloud
“We’ve been engaged with Microsoft for some years to get all of our on-premises workloads into the Azure cloud, mainly for flexibility and cost,” says Richard Matt, Associate Director, Business Technology at Cambridgeshire and Peterborough NHS Foundation Trust. “As an NHS Trust we have to ensure we have best value for spend. It is difficult to justify expensive data centres on premises when Microsoft Azure is a far more sensible option.”
By 2020, the Trust had moved most office workloads and file storage from on-premises server rooms to Microsoft Azure, SharePoint and OneDrive. When this timely move supported the rapid enablement of remote working during the pandemic, the Trust’s internal awareness of the benefits of cloud technologies was cemented.
As a result, when the Trust needed to find a solution for an electronic patient records (EPR) system migration in 2020, Microsoft Azure felt like a natural choice.
Dealing with legacy, archive and live data
Cambridgeshire and Peterborough NHS Foundation Trust held legacy data from 1997 to 2013 in its clinical data library (CDL), data from 2013 to 2020 in its existing RiO EPR system and in an associated on-premises data warehouse.
“We needed to provide this data to clinicians, but to make this data available in the new EPR platform would be a very lengthy and expensive process,” explains Richard Matt.
The Trust needed to move more than three million clinical documents, plus structured data from the previous EPR system in over 300 user-defined data capture forms.
“Our new EPR provider estimated a 48-week data migration window. Our timeline with the contract of our previous EPR meant that was impractical,” recalls Jonathon Artingstall. “Another supplier was going to charge us £250k per feed and, with three data feeds, that was too expensive.”
Understanding the art of the possible
In January 2020, the Trust approached its Microsoft account team for advice. Richard Matt recalls, “We engaged with the team at Microsoft to ask ‘what’s the art of the possible here?’.”
“It was really exciting when we looked at what Microsoft was offering,” reports Jonathon Artingstall. “We wanted in on Microsoft’s future roadmap. When we were on premises, those technologies were always a little bit out of reach, so an important driver to move to Microsoft Azure was to embrace some of the technologies we knew were coming.”
The Trust wanted to adopt Azure Active Directory, Exchange Online and modern server infrastructure and services for easier management and security of its environments, but it was also excited by the possibilities around data, including Azure’s AI tools and capabilities.
Making the switch
“Microsoft was really supportive,” recalls Jonathon Artingstall. “The option to develop inhouse with Microsoft Azure and Azure Cognitive Search would meet our timeline and budget. We could see the potential, but we didn’t know what we didn’t know. Through the support we had from Microsoft, we were able to convince the board our internal team should develop the solution on Azure.”
“We’ve had a long and very positive relationship with Microsoft,” emphasises Richard Matt, “Our Unified Support contract enables us to access these resources and they’ve facilitated a lot of development. I don’t think we have that level of engagement with any other supplier.”
Work began in June 2020. Jonathon Artingstall says, “We came to this fairly wet behind the ears, but we stood up the solution very quickly. Microsoft helped and supported our inhouse development team to stand up the environment, to load the data and to provide an interface on the top of it which was fantastic.”
With support from the Microsoft team, the Trust’s internal team developed the solution on schedule. It went live in October 2020. Jonathon Artingstall says, “The development was relatively easy. It was the volumes that were challenging.”
Doing more with less
Undertaking the work internally on Microsoft Azure has boosted both skills and engagement in the Trust’s internal IT team.
“This project has really excited the team,” enthuses Jonathon Artingstall. “People really got behind it. They could see the technology they were working with. And the work is something the team is proud about; they can see the benefits. They can see how they, as back-office staff, are contributing to patient care. It is a nice thing for them to come to work every day to do.”
Alongside its development work, the team also dedicated time to converting the EPR data to a flat structured question and answer format.
“We created a better solution in half the time whilst also doing other work,” states Jonathon Artingstall, “We saved around £700k on the install costs. By using Microsoft Azure we created a better solution and it’s cheaper.”
New search capabilities
“Some of the features of Azure Cognitive Search – such as the ability to search handwritten notes – is just mind blowing,” says Richard Matt. This performance prompted the team to adjust some of its plans.
“We did plan originally to take the free text, use Optical Character Recognition (OCR) and then make it structured text,” explains Jonathon Artingstall. “But we didn’t need to do that because the Azure Cognitive Search just searched everywhere.”
Richard Matt enthuses, “When one of our senior clinicians was testing it out, he was pulling handwritten PDFs for his search term.”
Easy and secure to use
On the front end, the Azure Cognitive Search tool is accessible to users via a secure webpage authenticated against the user’s Azure Active Directory account. “All that authentication happens seamlessly in the user environment,” explains Richard Matt. “The benefit to the user is there’s no extra sign in. It works very smoothly while ensuring the level of security we need.”
Through this, clinicians have access to 23 years of data in a way that was impossible before.
Jonathon Artingstall explains, “A single patient’s case notes could have 2,000 documents. It’s unwieldly; in the past, if you needed information that is stored 1,600 documents ago, you weren’t going to find it. Now, using Azure Cognitive Search, this will take, literally, three seconds to search for a keyword across the 2,000 documents and to find it – it’s amazing. Our clinicians were blown away.”
“And it is more than that,” he continues. “The first time we demoed it, we weren’t too sure about the performance. With the resources we’d allocated, it was slow. So we ramped them up and within 15 minutes the speed was fantastic. It was a real indication of the flexibility that Azure gives us.”
Wow-ing clinicians with the search performance
“When we demoed the system to senior clinicians, they were blown away by how fast it was,” reports Richard Matt.
Chris O’Loughlin, Consultant Psychiatrist for Cambridge and Peterborough NHS Foundation Trust, explains, “It’s extremely helpful to be able to find information from previously held records, given our patients often have difficulties stretching over many years. The system is very usable and fast.”
Chess Denman, the Trust’s Medical Director at the time, commented, “It’s a triumph – really spectacular. Do people realise what this can do? It’s game changing. We should be trumpeting this very loudly!”
“I find it enormously helpful,” adds Rudolf Cardinal, Honorary Consultant Psychiatrist at Cambridge University Hospital. “It’s certainly better for finding content than our old EPR. The team did a cracking job at a fraction of the cost of other solutions. I’d be interested in adding data from other clinical systems as it works so well.”
Making data available so it can be put to good use
The Trust’s IT team is already looking at ways to further leverage its work. The data is already available anonymised and with ethics approvals for research direct from the Azure platform. The next phase is to securely widen the availability of information.
Jonathon Artingstall adds, “We’ve used the Azure Integration Services to switch on a live feed from our new EPR system to Microsoft Azure. From there, we will feed into other applications to give real-time information. All of these capabilities wouldn’t have been in place if we had stayed on-premises.”
“Our ambition is to expand this beyond the EPR data,” states Richard Matt. “The legacy finance data is really difficult to interrogate. And why stop there? There are employee records. And legacy paper records…”
“The obvious thing would be to add them to the archive in Microsoft Azure so we can give it the cognitive search capabilities,” agrees Jonathon Artingstall, “And, to make it as easy as possible for our clinicians to access data, we have now invested heavily in Power BI and its analytical functions as well.”
Benefitting from the flexibility of Microsoft Azure
“In the old systems, the documents were not being used because information was pretty much impossible to search, hard to find and hard to do anything with,” says Jonathon Artingstall. “The cognitive search helped with consolidating pockets of data. Now, the clinicians go into one system to look at 23 years’ worth of data. I don’t think I’ve seen another solution that does what this does. I’d definitely recommend it to other Trusts.”
“Because these three million documents are in archive, we stood up quite a fast box initially so it is responsive interface with the clinicians,” he continues. “As time goes on, we know more and more of the data will be in the new clinical system and not the archive, so we can scale that back to make cost savings. That cloud functionality to flex resources is important to optimise cost savings.”
Azure will also help to manage the retention period of records. “With the tools built into Azure Storage, we can label and classify any data, and then apply rules that manipulate that data based on those labels,” Richard Matt explains.
“And we can use the audit capabilities in Microsoft Azure,” confirms Jonathon Artingstall.
Embedding knowledge in the internal team for an exciting future
The IT leadership are keen to build on recent achievements.
“During this project, we used a lot of the Microsoft learning resources online,” says Jonathon Artingstall. “We were learning as we were doing. Although we went in fairly blind, we managed to do it, thanks in part to the help from Microsoft. But I’d probably recommend to others to do the Microsoft Certifications first, if the schedule allows.”
Richard Matt sees this as a further benefit for the staff who have worked so well on this project. Through the Enterprise Skills Initiative and its Unified Support contract, the Trust has access to learning and certifications resources from Microsoft. He says, “We will be looking at certification this year and hope to get staff through the Microsoft certifications.”
At the same time, the team is setting new ambitions for its use of the data it has moved into Microsoft Azure.
Jonathon Artingstall explains, “We’re currently developing a proof of concept with the NHS Skunkworks team to look at the potential of applying AI on the data. We want to quantify pretext data to make it more useful; to look at what valuable insights we can extract from the free text using NLP and AI, particularly around SNOMED codings – and whether we can make that free text meaningful in terms of service evaluation or a patient outcomes focus. We’re excited by it. The roadmap that Microsoft is offering opens lots and lots of doors.”
“The roadmap that Microsoft is offering opens lots and lots of doors.”
Jonathon Artingstall, Associate Director Information & Performance, Cambridgeshire and Peterborough NHS Foundation Trust
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